Print Form
Medical History
Patient Name
Nickname
Age
Name of Physician/and their specialty
Most recent physical examination
Purpose
What is your estimate of your general health?
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
YES
NO
1. hospitalization for illness or injury
2. an allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulpha
local anesthetic
fluoride
metals (nickel, gold, silver
)
latex
other
3. heart problems, or cardiac stent within the last six months
4. history of infective endocarditis
5. artificial heart valve, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. artificial prosthesis (heart valve or joints)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. emphysema, sarcoidosis
14. tuberculosis
15. asthma
16. breathing or sleep problems (i.e. snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes (HbA1c =
)
24. stomach or duodenal ulcer
25. digestive disorders (i.e. gastric reflux)
YES
NO
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthritis
28. glaucoma
29. contact lenses
30. head or neck injuries
31. epilepsy, convulsions (seizures)
32. neurologic problems (attention deficit disorder)
33. viral infections and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. venereal disease
37. hepatitis (type
)
38. HIV / AIDS
39. tumor, abnormal growth
40. radiation therapy
41. chemotherapy
42. emotional problems
43. psychiatric treatment
44. antidepressant medication
45. alcohol / drug dependency
ARE YOU:
46. presently being treated for any other illness
47. aware of a change in your general health
48. taking medication for weight management (i.e. fen-phen)
49. taking dietary supplements
50. often exhausted or fatigued
51. subject to frequent headaches
52. a smoker or smoked previously
53. considered a touchy person
54. often unhappy or depressed
55. FEMALE - taking birth control pills
56. FEMALE - pregnant
57. MALE - prostate disorders
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.
List all medications, supplements, and or vitamins taken within the last two years
Drug
Purpose
Drug
Purpose
Ask for an additional sheet if you are taking more than 6 medications
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient’s Signature
Date
Doctor’s Signature
Date
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